Introduction

In a published opinion authored by Judge Helene N. White, the Sixth Circuit affirmed the convictions and sentences of Jeffrey Campbell (a physician-owner) and Mark Dyer (a nurse practitioner) of Physicians Primary Care (PPC), arising from an opioid-prescribing operation and an insurance-billing scheme. The jury convicted both defendants of conspiracy to unlawfully distribute controlled substances (21 U.S.C. § 846), health-care fraud and conspiracy to commit health-care fraud (18 U.S.C. §§ 1347, 1349), and money laundering (18 U.S.C. § 1956), while acquitting on various substantive distribution counts and death-resulting counts.

On appeal, defendants raised multiple challenges: (1) jury instructions under the Controlled Substances Act in light of Ruan v. United States; (2) sufficiency of the evidence on conspiracy to distribute controlled substances, health-care fraud, and promotion money laundering; (3) several evidentiary rulings related to expert and lay testimony and summary charts; (4) sentencing determinations concerning drug quantity and intended loss; and (5) restitution. The court affirmed across the board and declined to review restitution because no separate notice of appeal was filed after the later restitution order, as required by Manrique v. United States.

The opinion’s principal legal contribution is to cement, within the Sixth Circuit, that a deliberate-ignorance instruction—properly framed—adequately conveys Ruan’s subjective mens rea requirement, not only for substantive § 841 prosecutions but also for § 846 conspiracies by medical practitioners, even when the elements instruction does not explicitly require knowledge of unauthorized prescribing. The court again cautions that these are not the model instructions going forward.

Summary of the Opinion

• Jury instructions: Although the trial predated Ruan, appellate review applies current law. The court acknowledged that the elements instructions did not expressly require knowledge that conduct was unauthorized. Nevertheless, binding circuit precedents (Anderson, Bauer, Stanton) hold that a deliberate-ignorance instruction juxtaposed with warnings that negligence/carelessness do not suffice “substantially covers” Ruan’s subjective mens rea, including for § 846 conspiracies. The panel therefore found no reversible error under either harmless- or plain-error review.
• Sufficiency—§ 846 conspiracy: Ample circumstantial evidence supported an agreement, knowledge, and participation in a conspiracy to unlawfully distribute (e.g., pre-signed scripts, cursory exams, failed drug screens, high-volume prescribing, out-of-state patients). Apparent verdict inconsistency across counts does not warrant reversal under United States v. Powell. Randolph is distinguishable because it involved inconsistency within a single count’s findings.
• Sufficiency—health-care fraud and conspiracy: Evidence supported fraudulent “incident-to” billing for exercise (MedFit), counseling, and physical therapy using code 99214, contrary to payer rules (Medicare/Indiana Medicaid requiring physician supervision and plan; Kentucky Medicaid barring incident-to). Evidence of defendants’ knowledge and provider agreements supported intent to defraud.
• Sufficiency—promotion money laundering: Insurance proceeds from the fraud funded bonuses that incentivized continued fraud; the record permitted findings that defendants knew the funds were criminal proceeds and intended to promote the scheme.
• Evidentiary rulings: No abuse of discretion in admitting expert testimony on professional norms (necessary to show “usual course” and legitimate medical purpose); any references to 2016 CDC guidelines were non-prejudicial; a summary bar graph comparing bonuses was admissible; an experienced DEA investigator could offer opinion testimony without formal “certification” as an expert; and any error in a lay witness’s qualitative characterization was harmless.
• Sentencing: The district court’s drug-quantity estimate (supported by expert testimony and conservative reductions) was not clearly erroneous. The use of intended loss is permissible under Sixth Circuit precedent (You). Any error in loss calculation was harmless because the court imposed substantial downward variances and explicitly stated it would impose the same sentences under the § 3553(a) factors regardless of the Guidelines range.
• Restitution: Not reviewable because defendants failed to file a separate notice of appeal from the later restitution order, as required by Manrique.

Analysis

Precedents Cited and Their Influence

• Ruan v. United States, 597 U.S. 450 (2022): Ruan held that § 841’s “knowingly or intentionally” mens rea applies to authorization, requiring proof that the defendant knew or intended that the prescribing was unauthorized (i.e., lacked a legitimate medical purpose or was outside the usual course). Campbell extends Ruan’s logic to § 846 conspiracies by recognizing that after Ruan, a conspirator cannot “knowingly” agree to violate § 841 unless he agrees to commit unauthorized acts.
• United States v. Anderson, 67 F.4th 755 (6th Cir. 2023); United States v. Bauer, 82 F.4th 522 (6th Cir. 2023); United States v. Stanton, 103 F.4th 1204 (6th Cir. 2024): This trilogy controls the result. Anderson held that a deliberate-ignorance instruction that contrasts knowledge from carelessness/negligence can “substantially cover” Ruan. Bauer applied that approach on plain-error review and acknowledged that such instructions are not ideal but adequate; it also found that an “objectively reasonable good faith” gloss muddies the water but does not alone compel reversal. Stanton extended the same logic to § 846 conspiracies, stating that a deliberate-ignorance instruction can satisfy Ruan if it sets a standard well above carelessness or negligence.
• United States v. Houston, 792 F.3d 663 (6th Cir. 2015): Appellate courts measure jury instructions against the law at the time of appellate consideration, allowing post-Ruan assessment even though the trial preceded Ruan.
• Conspiracy and sufficiency: United States v. Potter, 927 F.3d 446 (6th Cir. 2019); United States v. Hall, 20 F.4th 1085 (6th Cir. 2022); United States v. Beals, 698 F.3d 248 (6th Cir. 2012) (agreement, knowledge/intent, participation; circumstantial evidence suffices). United States v. Wheat, 988 F.3d 299 (6th Cir. 2021) (conspiracy must involve more than a single transfer). The opinion relies on typical pill-mill indicia (crowded clinic, brief exams, pre-signed scripts, travel distances).
• Inconsistent verdicts: United States v. Powell, 469 U.S. 57 (1984) (inconsistency across counts is generally not grounds for reversal); United States v. Lawrence, 555 F.3d 254 (6th Cir. 2009) (same); United States v. Randolph, 794 F.3d 602 (6th Cir. 2015) (reversal only where the inconsistency appears within the same count).
• Health-care fraud: United States v. Persaud, 866 F.3d 371 (6th Cir. 2017) (elements of § 1347); United States v. Hughes, 505 F.3d 578 (6th Cir. 2007) (elements of § 1349 conspiracy). The opinion applies payer-specific rules (Medicare/Medicaid “incident-to” conditions; Kentucky Medicaid prohibitions) to show falsity and intent.
• Money laundering: United States v. Tolliver, 949 F.3d 244 (6th Cir. 2020) (elements of § 1956 conspiracy, including promotion intent).
• Evidence: United States v. Volkman, 736 F.3d 1013 (6th Cir. 2013) (government may reference objective medical norms to show acting outside the usual course); United States v. Maliszewski, 161 F.3d 992 (6th Cir. 1998) (harmlessness of minor evidentiary missteps); United States v. Bray, 139 F.3d 1104 (6th Cir. 1998) (limits on summary charts); United States v. Weinstock, 153 F.3d 272 (6th Cir. 1998) (Rule 403 and charts); United States v. Johnson, 488 F.3d 690 (6th Cir. 2007), United States v. Neeley, 308 F. App’x 870 (6th Cir. 2009) (no need to “certify” experts before the jury; foundation suffices); United States v. Gowder, 841 F. App’x 770 (6th Cir. 2020) (officer qualified to discuss pill-mill characteristics).
• Sentencing: United States v. Jeross, 521 F.3d 562 (6th Cir. 2008) (drug quantity estimates); United States v. Walton, 908 F.2d 1289 (6th Cir. 1990) (erring on side of caution); United States v. Mosley, 53 F.4th 947 (6th Cir. 2022) (deference to credibility findings); United States v. You, 74 F.4th 378 (6th Cir. 2023), applying Kisor v. Wilkie, 588 U.S. 558 (2019) (Guidelines ambiguity permits reliance on commentary defining loss to include intended loss); Williams v. United States, 503 U.S. 193 (1992); Molina-Martinez v. United States, 578 U.S. 189 (2016); United States v. Obi, 542 F.3d 148 (6th Cir. 2008); United States v. O’Georgia, 569 F.3d 281 (6th Cir. 2009) (harmlessness of Guidelines error when court would impose the same sentence after considering § 3553(a)).
• Charging sufficiency: Almendarez-Torres v. United States, 523 U.S. 224 (1998); United States v. Olive, 804 F.3d 747 (6th Cir. 2015) (indictment sufficiency standards—met here).
• Restitution: Manrique v. United States, 581 U.S. 116 (2017) (separate notice of appeal required for later-entered restitution orders).

Legal Reasoning

The centerpiece is the court’s application of Ruan to § 846 conspiracy charges against medical practitioners. The panel agreed that after Ruan, a conspiracy to unlawfully distribute controlled substances requires proof that conspirators knew (or intended) their prescribing conduct was unauthorized. The panel also candidly noted that the district court’s elements instructions did not expressly state this subjective-authorization knowledge requirement. Still, under Anderson, Bauer, and Stanton, a carefully worded deliberate-ignorance instruction can “substantially cover” Ruan if it:

• Permits the jury to infer knowledge from intentional blindness to a high probability of unauthorized prescribing, and
• Explicitly distinguishes knowledge from carelessness, negligence, mistake, or foolishness.

The panel reinforced two clarifications:

• “Good-faith” language framed in objective terms (e.g., “what a reasonable doctor would believe”) is disfavored after Ruan and “muddies the water,” but does not override the adequacy of a proper deliberate-ignorance instruction under binding circuit precedent.
• References to patient diversion within the deliberate-ignorance instruction do not improperly “equate” diversion with lack of authorization; rather, they allow knowledge of diversion to be inferred from deliberate blindness to diversion. The instruction still required proof of knowing unauthorized conduct.

On sufficiency, the panel underscored that pill-mill indicia (cursory exams, pre-signed scripts, high-volume opioid prescribing to >90% of patients, long-distance travel, scripts after failed drug screens) permit a rational jury to find an unlawful distribution conspiracy. The panel rejected the defendants’ attempt to leverage acquittals on particular § 841 counts to unravel the § 846 conspiracy verdict, reiterating Powell’s rule that inconsistency across counts is not a basis for reversal because verdicts may reflect lenity or compromise. Randolph remains limited to internal, same-count inconsistencies.

For health-care fraud, the court carefully distinguished legitimate “incident-to” billing from defendants’ practices. Credentialing documents, payer policies (e.g., Medicare/Indiana Medicaid requiring physician supervision and a physician-created plan of care; Kentucky Medicaid forbidding incident-to), minimal clinician involvement, and use of a non-clinician “pool guy” supervising exercise all supported falsity and intent to defraud. Defendants’ provider agreements and testimony about their understanding of 99214 requirements underpinned scienter.

On money laundering, the panel accepted the government’s promotion theory: the business used fraud proceeds to pay large bonuses to drive additional fraudulent billing. The record permitted findings that defendants knew the proceeds’ illicit source and intended to promote the scheme’s continuance.

The evidentiary rulings fell well within the district court’s discretion. Expert testimony on medical norms is not only admissible but often indispensable in Controlled Substances Act cases to establish deviation from the “usual course of professional practice.” The fleeting mention of 2016 CDC guidelines did not prejudice defendants; both experts disclaimed reliance on them, and the concept of “start low, go slow” was a longstanding general medical principle. The summary bar graph complied with Rules 1006 and 403, as it accurately summarized bonus data without argumentative annotations; disputes over “why” the bonuses were high were for the parties to argue. The DEA investigator’s testimony was properly admitted opinion testimony supported by experience and training, without the need to “certify” him as an expert in front of the jury. The lay witness’s qualitative characterization was, at worst, harmless given the breadth of corroborating evidence.

On sentencing, the drug-quantity estimate relied on expert testimony and conservative methodologies (selecting a small subset of patient files from a multi-year span, excluding acquitted counts, and applying a one-third reduction) and was not clearly erroneous. With respect to intended loss, the Sixth Circuit’s decision in You permits reliance on the Guidelines commentary defining “loss” to include intended loss. Furthermore, even assuming arguendo any error in loss figures, the district court expressly varied downward and stated on the record it would impose the same sentences based on § 3553(a), rendering any Guidelines error harmless under Williams, Molina-Martinez, Obi, and O’Georgia. Finally, the restitution challenge was jurisdictionally barred under Manrique because defendants failed to file a separate notice of appeal after the later restitution order.

Impact and Prospective Significance

• Jury instructions in medical-prescriber cases: This opinion further entrenches the Sixth Circuit’s post-Ruan approach that a properly framed deliberate-ignorance instruction can satisfy Ruan’s subjective-authorization mens rea, including in § 846 conspiracies. However, the panel reiterates that these are not the preferred instructions going forward. District courts should update elements instructions to explicitly require proof that the defendant knew or intended that his prescribing was unauthorized; defense counsel should preserve requests for such instructions and object to “reasonable doctor” good-faith formulations.
• Government trial strategy: Prosecutors in health-care prescriber cases can continue to use deliberate-ignorance instructions where supported by the evidence, while ensuring the charge clearly distinguishes knowledge from negligence. Evidence of clinic operations—volume, speed, pre-signing, failed drug screens, travel distances, and non-clinician supervision—remains powerful circumstantial proof of agreement and knowledge.
• Health-care fraud prosecutions: The decision underscores close scrutiny of “incident-to” billing. Payer-specific rules and prohibitions matter: prosecutors should prove the governing policy at the time and the defendant’s notice of those rules; defense teams must be prepared with payer policies, supervision documentation, and care plans if relying on “incident-to.”
• Money laundering exposure: Paying staff bonuses with fraud proceeds to incentivize further billing can supply promotion intent under § 1956. Compliance programs should scrutinize bonus structures tied to reimbursable activity to ensure they are not funded by or designed to drive unlawful claims.
• Evidence practice: The court confirms that expert testimony on standards of care is central and admissible; agents with relevant experience may offer opinion testimony without theatrical “expert certification.” Summary charts must accurately reflect admissible data and avoid argumentative captions.
• Sentencing and loss: In the Sixth Circuit, intended loss remains a permissible basis for fraud enhancements. District judges should make clear, alternative § 3553(a) rationales to insulate sentences from Guidelines miscalculations. Defense counsel should build a record of conservative estimates, exclusions, and reductions to challenge quantity and loss.
• Appellate practice—restitution: Manrique’s separate-notice requirement is strictly applied. Counsel must file a new notice of appeal after entry of a later restitution order to preserve challenges to restitution amounts.

Complex Concepts Simplified

• Ruan’s mens rea rule: In doctor-prescribing cases, the government must prove the defendant doctor knew or intended that his prescribing was unauthorized—not merely that a “reasonable doctor” would disagree. It is a subjective standard focused on the actual defendant’s mind.
• Deliberate ignorance (willful blindness): If a person strongly suspects a fact (e.g., that prescribing is unauthorized) and deliberately avoids confirming it, a jury may treat that as knowledge. But negligence or carelessness is not enough; it requires conscious avoidance.
• § 846 conspiracy liability: To convict of conspiracy to unlawfully distribute, the government must show an agreement to violate the drug laws, that the defendant knowingly joined intending to achieve the objective, and that he participated. After Ruan, “knowingly” joining means agreeing to unauthorized prescribing.
• Incident-to billing: A Medicare billing concept that sometimes allows billing under a physician’s name for services furnished by non-physician practitioners, but only if strict supervision and plan-of-care requirements are met—and some payers (e.g., Kentucky Medicaid in this case) do not allow it at all.
• Inconsistent verdicts across counts: Courts will not overturn a conviction just because a jury acquitted the same defendant on a different count involving similar facts; juries can be merciful, compromise, or err. The question on appeal is whether the conviction count is supported by sufficient evidence.
• Intended loss vs. actual loss: For fraud sentencing, “loss” can be either the actual money lost by victims or the amount the defendant intended to cause to be paid unlawfully—even if the full amount was not paid.
• Promotion money laundering: Using criminal proceeds to pay expenses that further or expand the crime (e.g., bonuses to drive more fraudulent billing) can constitute money laundering designed to promote the unlawful activity.
• Manrique restitution rule: If restitution is set after the original judgment, you must file a separate notice of appeal from the later restitution order; otherwise, an appellate court cannot review the amount.

Conclusion

United States v. Campbell reinforces the Sixth Circuit’s approach to post-Ruan prescribing prosecutions: a deliberate-ignorance instruction, framed to emphasize subjective knowledge and to exclude negligence, can adequately convey the mens rea Ruan demands—even in § 846 conspiracies involving medical practitioners—despite less-than-ideal elements language. The court sustains convictions for health-care fraud and promotion money laundering grounded in improper “incident-to” billing and the use of fraud proceeds to incentivize further fraud. It upholds pragmatic evidentiary rulings central to pill-mill prosecutions and reaffirms that intended loss remains available for Guidelines purposes, with sentences insulated by explicit § 3553(a) reasoning. Finally, the opinion is a cautionary tale on appellate procedure: restitution determined later requires its own notice of appeal.

The decision’s significance lies in its clear guidance to trial courts and litigants: modern prescriber cases must honor Ruan’s subjective standard, but willful-blindness instructions remain a powerful tool; payer-specific billing rules are dispositive in health-care fraud; and careful sentencing records can render Guidelines disputes harmless. Campbell therefore consolidates existing Sixth Circuit doctrine into a practical roadmap for post-Ruan prosecutions and defenses in the intersection of controlled substances and health-care fraud.